Alimentary-constitutional obesity: degrees and treatment. Alimentary-constitutional obesity - what is it Obesity of the 1st degree of alimentary constitutional genesis

Graduate work

Psychological characteristics of people suffering from alimentary-constitutional obesity.

Introduction

Relevance: In most economically developed countries of the world, there is a clear trend towards an increase in the number of patients with eating disorders, accompanied by severe somatoendocrine disorders and causing persistent psychosocial maladjustment (Krylov V.I., 1995). Changing eating behavior is one of the types of pathological adaptation and underlies food addiction, which is a socially acceptable type of addictive behavior - condemned, but not dangerous to others. Using excessive food intake as a means of avoiding reality and normalizing the emotional state, an addictive person “acquires” new problems in the form of alimentary-constitutional obesity, indicating spiritual distress. However, the relationship between disturbed eating behavior and the psychological characteristics of a person suffering from overweight remains poorly understood to date (Powers P. S. et al., 1988, 1992; Shapiro S., 1988).

Appetite regulation is a complex multicomponent mechanism, one of the most important links of which is the reciprocal interaction of the satiety center and the hunger center located in the hypothalamus (Brobeck, 1946; Bray, 1976; Gallaugher, 1981; Bray, 1982). In recent years, more and more work has appeared, indicating that the satiety signal triggers complex reactions of the hypothalamic-pituitary and limbic systems, some of which are associated with positive emotions. According to A.M. Wayne (1981), there is a close relationship between mental, emotional and vegetative processes that underlie the adaptation of the body to various stimuli of the external and internal environment. In a situation of developed family stereotypes of the cult of food with a lack of positive emotions, a person can use food intake as a compensatory way to normalize the emotional background (Korosteleva I.S. et al., 1994). Overeating becomes a source of positive emotions, an adaptation option under adverse social conditions or mental distress (Knyazev Yu.A., Bushuev S.L., 1984; Gavrilov M.A., 1999; Rotov A.V., 2000).

Thus, the above determines the relevance of the study of the psychological factors underlying obesity and determines the following goals and objectives.

Purpose: To identify the psychological characteristics of obese people.

1. Conduct psychodiagnostics of people with alimentary-constitutional obesity and normal weight as a control group.

2. Determine the psychological factors associated with the formation of obesity in overweight people.

3. Determine the indications and formulate recommendations for providing psychological assistance (psychotherapy) for obesity.

Hypothesis: People with alimentary-constitutional obesity are characterized by certain psychological characteristics: hypochondria, anxiety, escape from reality.

Object: Psychological characteristics of people with alimentary-constitutional obesity.

Subject: Indications for psychotherapy of people with alimentary-constitutional obesity.

Organization, materials, research methods:

3. Psychodiagnostic methods of OHP (Karvasarsky B.D., Wasserman L.I. Iovlev B.V. 1999), MMPI (Minnesota Multiphasic Personality Inventory) modified by Berezin F.B. (Berezin F.B., Miroshnikov M.P., Rozhanets R.V. 1976)

4. Method for determining the Quetelet body mass index (degree of obesity). (Vardimiadi N.D., Mashkova L.G., 1988)

1. Obesity - concept, classification

In recent decades, overweight and obesity have become one of the most important problems for the inhabitants of most countries of the world.

According to the latest World Health Organization (WHO) estimates, more than a billion people on the planet are overweight. This problem is relevant even for countries in which a large part of the population is constantly starving. In industrialized countries, obesity is already a significant and serious aspect of public health. This problem has affected all segments of the population, regardless of social and professional affiliation, age, place of residence and gender. In Western European countries, for example, 10 to 20% of men and 20 to 25% of women are overweight or obese. In some regions of Eastern Europe, the proportion of obese people has reached 35%. In Russia, on average, 30% of people of working age are obese and 25% are overweight. Most obese people in the United States: in this country, overweight is registered in 60% of the population, and 27% are obese. According to experts, obesity is the cause of premature death of about three hundred thousand Americans a year. In Japan, representatives of the society for the study of obesity, who first prepared a special declaration, say that overweight and obesity in the Land of the Rising Sun are becoming a tsunami, threatening the health of the nation.

There is an increase in the incidence of obesity in children and adolescents everywhere. In this regard, WHO considers this disease as a pandemic affecting millions of people.

Obesity and all the problems associated with it are becoming an increasingly heavy economic burden on society. In the developed world, obesity treatment accounts for 8-10% of all annual healthcare costs.

A feature of obesity is that it is often combined with serious diseases that lead to a reduction in the life expectancy of patients:

type 2 diabetes mellitus.

arterial hypertension,

dyslipidemia,

atherosclerosis,

ischemic heart disease,

sleep apnea syndrome,

Some types of malignant neoplasms

reproductive dysfunction,

Diseases of the musculoskeletal system.

It's no secret that being overweight is one of the health indicators. Extra pounds significantly increase the risk of developing such serious diseases as arterial hypertension, type 2 diabetes, coronary heart disease, so it is very important to monitor your weight. The main sign of obesity is the accumulation of adipose tissue in the body: in men, more than 10-15%, in women, more than 20-25% of body weight.

Obesity is:

accumulation of fat in the body, leading to an increase in excess body weight. Obesity is characterized by excessive deposition of fat in the body's fat depots.

the result of calorie intake from food that exceeds calorie expenditure, that is, the result of maintaining a positive energy balance for a long time.

chronic relapsing disease characterized by excessive accumulation of adipose tissue in the body.

chronic disease requiring long-term medical treatment and monitoring aimed at stable weight loss, reduction of comorbidities and mortality. Up to 75% of patients on a diet (especially a very low calorie diet - about 400-800 kcal / day) gain most of the weight lost within 1 year.

Obesity classification:

I. Primary obesity. Alimentary-constitutional (exogenous-constitutional):

1. Constitutionally-hereditary;

2. With eating disorders (night eating syndrome, increased food intake for stress);

3. Mixed obesity.

II. secondary obesity.

1. With established genetic defects:

2. Cerebral obesity;

brain tumors;

trauma to the base of the skull and the consequences of surgical operations;

syndrome of an empty Turkish saddle;

skull trauma;

inflammatory diseases (encephalitis, etc.).

3. Endocrine obesity:

pituitary;

hypothyroid;

climacteric;

adrenal;

mixed.

4. Obesity on the background of mental illness and / or taking antipsychotics.

Stages of obesity:

a) progressive;

b) stable.

Types of obesity:

1. "Upper" type (abdominal), male

2. "Lower type" (femoral-gluteal), female

Fat can be located:

1. In subcutaneous fat (subcutaneous fat)

2. Around internal organs (visceral fat)

Abdominal subcutaneous fat + abdominal visceral fat = abdominal fat.

The deposition of fatty tissue in the abdominal region (upper type of obesity, or central obesity) is more clearly associated with morbidity and mortality than the lower type of obesity or than the degree of obesity!

Numerous studies have shown that a large amount of abdominal adipose tissue is associated with a high risk of developing dyslipidemia, diabetes, and cardiovascular disease. This relationship is not related to total body fat. For the same body mass index (BMI), abdominal obesity, or increased fat deposition in the abdomen, is associated with a higher risk of developing comorbidities than lower-type obesity.

Abdominal fat distribution increases the risk of mortality in men and women. Preliminary evidence also suggests an association between this type of fat deposition and sarcoma in women.

Recall that the simplest indicator of the distribution of adipose tissue is the OT / OB index (the ratio of waist to hips).

A high value of the ratio OT / OB means the predominant accumulation of adipose tissue in the abdominal region, i.e. in the upper body. Men and women are at risk if OT / OB is greater than or equal to 1.0 and 0.85, respectively.

For men OT/R 1.0

For women OT / OB 0.85.

Obesity related diseases and risk factors:

According to WHO, obesity of the first, second, initial degree of the third (BMI 35-37) is dangerous for human health. BMI over 38 is a threat to life.

Many obese individuals have impaired function of insulin and carbohydrate metabolism, as well as cholesterol and triglyceride metabolism. All of these comorbid conditions are risk factors for cardiovascular disease, and their severity increases with increasing BMI (see table).

Relative risk of diseases often associated with obesity:

For example, in obese individuals, the relative risk of type 2 diabetes mellitus triples compared with the risk in the general population. Similarly, obese individuals double or triple their risk of coronary heart disease.

Obesity is often accompanied by the development of:

▪ type 2 diabetes

▪ impaired glucose tolerance

▪ elevated levels of insulin and cholesterol

▪ arterial hypertension

Obesity is an independent risk factor for cardiovascular disease. Body weight is a better predictor of coronary heart disease than blood pressure, smoking, or high blood sugar. Moreover, obesity increases the risk of other forms of pathology, including certain types of cancer, diseases of the digestive system, respiratory organs and joints.

Obesity significantly impairs the quality of life. Many obese patients suffer from pain, limited mobility, low self-esteem, depression, emotional distress and other psychological problems due to prejudice, discrimination and exclusion in society.

2. Psychosocial aspects of obesity

At the present stage of studying the problem of obesity, most researchers recognize the fact that the leading etiological factors of the disease are hyperalimentation and hypokinesia. Based on these basic ideas about the causes of obesity, various models of the pathogenesis of the disease are proposed. However, the statement of hyperalimentation and hypokinesia, which is the starting point when considering the neuro-humoral-endocrine and energy mechanisms of the disease, does not allow one to get an adequate idea of ​​the clinic and etiopathogenesis of the disease, since the actual human factor of the disease falls out of the analysis, i.e. such mechanisms of the pathological process that are determined by the social essence of a person.

To most accurately understand the essence of the psychosocial factors of obesity, it is necessary to analyze eating behavior.

An analysis of eating behavior cannot be carried out without highlighting the main constitutive feature - nutritional needs. The approach to revealing the content of human behavior, based on the identification of needs as an inciting and guiding force, is traditional for Soviet psychology.

Nutritional need, according to most researchers, refers to the lowest, natural, biological, primary physiological needs, from which it follows that nutritional need is one of the leading needs of the body, which indicates a lack of plastic and energy substances necessary to perform vital functions. However, nutritional need, being typically biological in nature and serving as an object for the psychophysiological study of motivation in animals, in humans in the process of socialization, as it were, "humanizes" and ceases to be a need only for plastic and energy substances, it appears in a more complex form "socialized" needs. This circumstance was emphasized by K-Marx: "Hunger is hunger, but the hunger that is quenched by boiled meat eaten with a knife and fork is a different hunger than that in which raw meat is swallowed with the help of hands, nails and teeth." A.N. Leontiev reveals an important feature of needs, pointing out that "in the most needful state of the subject, an object that is able to satisfy the need is not rigidly recorded." An analysis of the eating behavior of obese patients, to a certain extent, confirms this idea. Human eating behavior is psychologically polyfunctional. The polyfunctionality of eating behavior is especially clearly observed in patients with obesity, manifesting itself for all patients in the same way - hyperalimentation, but in essence it is different and depends on what needs the person satisfies, on its "personal meaning".

Eating behavior can be:

1. A means of maintaining energy and plastic homeostasis. This is the simplest form of eating behavior, when food serves only to meet the body's need for nutrients.

2. Means of relaxation, discharge of neuropsychic tension. In this form, eating behavior is found not only in humans, but also in animals. L.V. Waldman points out that cats in the depression-like stage of chronic stress show obsessive food motivation and food greed. Similar phenomena have been observed in humans.

3.G.I. Kositsky notes that during the war, during the bombing, some people experienced a pronounced feeling of hunger, and they ate the entire available supply of food. He draws attention to the fact that such manifestations are also encountered in peacetime with strong neuropsychic stress, explaining them on the basis of the stress state formula he proposed: CH = C (In-En-Vn - Is-Es-Sun), where CH - the state of stress, C-goal, In, En, Vn - information, energy, time required to fulfill this goal, and Is, Es, Vs - the resources of these parameters available to the body, respectively. From this, he concludes that the body reduces the state of tension, increasing energy resources through excessive food intake. Among the patients examined by us, 45.5% noted a pronounced feeling of hunger during neuropsychic stress caused by a variety of reasons, and that eating at this moment had a calming effect on them. It should be noted that patients mainly consumed easily and quickly digestible carbohydrate foods.

4. By means of delectation (delectatio - lat. - pleasure, enjoyment), sensual, sensory pleasure, acting as an end in itself.

4. A means of communication, when eating behavior is associated with communication between people, a way out of loneliness.

5. A means of self-affirmation. Eating behavior in this case is aimed at increasing the self-esteem of the individual. This behavior is manifested in the choice and reception of exotic, most refined and expensive dishes, active visits to restaurants. It is closely related to an inadequate idea of ​​the prestige of food and the corresponding "solid" appearance.

6. Means of knowledge. The process of eating always includes a cognitive component. Taste, visual, olfactory analyzers evaluate the quality of food, its safety and usefulness for the body.

7. A means of maintaining a certain ritual or habit. At the same time, eating behavior is aimed at maintaining national, family traditions, rituals and habits. An example of such behavior is traditional holiday feasts, the habit of eating while reading, watching TV, listening to music.

obesity nutritional psychotherapy treatment

8. A means of compensation, replacement of unsatisfied needs of the individual (need for communication, achievement, parental needs, sexual needs, etc.).

9. Means of reward. Food, due to its taste, can serve as a reward for some actions that are positively evaluated by the social environment. Especially often this form of eating behavior occurs in childhood.

10. A means of satisfying an aesthetic need. It is known that food, eating behavior of a person can be aimed at satisfying the aesthetic needs of a person. This is manifested both in the improvement of the taste of food through culinary processing, and in the process of eating through ritual, the use of beautiful tableware and cutlery.

11. Means of protection. R. Konechny and M. Bouhal indicate that excessive food intake, and after that the resulting change in appearance can serve as a means of protection against unwanted marriage (marriage), an excuse for failure in sports and work.

Thus, human eating behavior is aimed not only at providing the body with plastic and energy substances, but also performs a wide variety of functions, and in an individual, these functions always manifest themselves in a complex way.

The analysis of eating behavior reveals the most important feature of needs, the transformation of the object of one need into the object of another, masking the true motives of behavior. This transformation occurs under the influence of external factors, mediated by internal ones.

Psychosocial factors contributing to the occurrence of hyperalimentation. Clinical and psychological examination of obese patients made it possible to identify several types of psychosocial factors that contribute to the occurrence of hyperalimentation. It should be emphasized that the factors described in most cases do not act separately, but collectively.

1. Mental trauma. Psychological conflicts of personality, violations of inter - and (or) intrapersonal relationships contribute to excessive food intake. The influence of this factor was noted in 50% of the patients examined by us. The table presents data on psychotraumatic situations that contributed to the formation of hyperalimentation. As can be seen from the table, the largest percentage of psychotraumatic situations falls on the sphere of family and domestic relations, among which the leading role is dissatisfaction with family relations. An analysis of traumatic situations shows that they are found everywhere, and their influence is determined by the significant attitude of the patient's personality towards them. It is interesting to note that the same situations play an important role in the pathogenesis of neurosis, alcoholism, coronary heart disease, and hypertension. It is not possible today to answer the question why, in some cases, psychotraumatic situations that are significant for a person lead to the emergence of neurosis, alcoholism, coronary heart disease, hypertension, and in others to deformation of eating behavior and further development of obesity, today it is not possible and requires additional research. It seems that the personality traits of the patients and the constitutional inferiority of the food center can be the decisive moments.

2. Socio-cultural norms and traditions. This factor often plays a significant role in the formation of the wrong attitude to food and overweight.

a) The idea of ​​a large body weight (fatness) and a good appetite as signs of health.

b) The idea of ​​a large body weight and certain eating behavior as a sign of solidity, social well-being, prestige.

c) National and cultural food traditions.

3. Wrong education. The formation of an inadequate idea of ​​food and the corresponding food stereotypes in a patient is closely related to upbringing in the family, but we separately single out this group of factors in order to pay special attention to the dependence of improper upbringing and hyperalimentation.

a) Upbringing by the type of "hyper-custody". Exaggerated concern for the health of the child, overfeeding him, too careful attitude towards him, limiting his physical activity can lead to the development of obesity in children. This factor is the leading cause of childhood obesity.

b) Education according to the type of "rejection". The undesirability of the child in the family, and as a result of this upbringing according to the type of "rejection" can, as well as excessive guardianship, lead to overfeeding of the child. It can be assumed that the mother's unconscious feeling of undesirability of the child, the lack of love for him is replaced by the implementation of socially regulated norms. In these cases, the mother, as it were, is removed from the child, formally performing her parental functions, guided by the principle: "The child must be well fed, shod, dressed no worse than other children." Among our patients, this factor was detected in 8%. They noted frequent conflicts with their parents, an authoritarian, harsh upbringing, a feeling of undesirability in the family against the background of an exaggerated concern for their health and clothing.

As can be seen from the foregoing, there is a significant number of psychosocial factors that affect the eating behavior of a person, which are a kind of trigger mechanisms for the development of obesity.

3. Genetic aspects of obesity

The role of hereditary factors in the development of obesity was discussed as early as the 1960s, when Pickwick's syndrome was first described in siblings. And although the so-called twin method did not give unambiguous results, later twin studies convincingly testify in favor of a significant role of hereditary predisposition to obesity.

The existence of familial forms of obesity is well known, in which the inheritance coefficient reaches 25%, which indicates a rather high contribution of genetic factors to the development of this syndrome.

Yu.A. Knyazev and A.V. Kartelishev defined family forms as "constitutional-exogenous obesity". They hypothesized the existence of an adiposogenotype, which does not contradict the concept of multifactorial inheritance.

The risk of developing obesity in a person reaches 80% if both parents have it. The risk is 50% if only the mother is obese, about 40% if the father is obese, and about 7-9% if the parents are not obese.

Currently, the search for the obesity gene is underway, but apparently there are several such genes and they are localized on different chromosomes. There is evidence of the existence of a dominant obesity gene with weak expressivity. It is assumed that this gene is closely linked to the met oncogene on chromosome 7.

When discussing the genetic aspects of obesity, it is necessary to dwell on the existence of 2 main types of obesity - hypertrophic and hyperplastic (or hypercellular, multicellular). This division is based on a genetically determined and acquired number of adipocytes. The laying and increase in the number of these cells occur in the "critical period" of a child's life - from the 30th week of pregnancy until the end of the first year of postnatal life. The leading factors that determine the number of fat cells in the body are the level (quality) of nutrition and the genetically determined secretion of growth hormone - growth hormone (GH). This was evidenced by an increase in the concentration (synthesis) of growth hormone in pregnant women with diabetes mellitus and the presence of the number of adipocytes in the fetus and newborn. Growth hormone is known to increase cell proliferation in various organs. And excessive nutrition of a pregnant woman and overfeeding of a child in the first months of life stimulate the reproduction of adipocytes and, therefore, contribute to the development of hyperplastic obesity. This form of obesity often develops in early childhood, has a more severe course and is difficult to treat. Resistance to therapy is associated with the irreversibility of the number, but not the size of adipocytes.

One of the methodological approaches to the study of the hereditary nature of diseases is the search for possible relationships between genetically determined signs - the so-called genetic markers - and pathology. Among genetic markers of considerable interest are human leukocyte antigens (HLA), the existence of which was proved in 1959. A relationship has been established between the antigens of the HLA system and the timing of the onset of the disease, on the one hand, and the nature of the clinical course and prognosis, on the other. For example, work carried out in Western Siberia revealed a high association of HLA, B8, A11, B22 with juvenile diabetes mellitus and arterial hypertension.

Obesity may be a manifestation of some pathological conditions associated with a single origin. In 1988 The hypothesis of the so-called "metabolic syndrome" (MS) or "X" syndrome was advanced, emphasizing that all signs are due to primary (probably genetically determined) tissue insulin resistance. The full picture of MS includes the presence of insulin resistance, overweight, predominant deposition of fat in the trunk, essential hypertension, characteristic changes in the blood lipid spectrum, and impaired glucose tolerance, increasing to overt diabetes mellitus. Due to the combination of all these signs, patients with MS have a high risk of developing atherosclerosis, arterial hypertension, coronary heart disease, strokes, type II diabetes mellitus, etc. The earliest manifestation of insulin resistance syndrome is abdominal (upper, visceral) obesity.

4. The role of the endocrine system in the etiopathogenesis of obesity

Speaking about the state of the endocrine system in obesity and its role in the genesis of the latter, it is extremely difficult to differentiate endocrine disorders that lead to weight gain from endocrine disorders that occur as a result of this increase.

A number of hormones are involved in the regulation of fat metabolism, both in the hypothalamic-pituitary region - corticolebyrin (CRF), adrenocorticotropic hormone (ACTH), growth hormone (GH, growth hormone) - and peripheral endocrine glands - cortisol and norepinephrine (adrenal glands), thyroid hormones (thyroid iron), insulin (pancreas), androgens, estrogens and progesterone (sex glands, adrenal glands), not to mention the hormone of adipose tissue - leptin. Androgens and estrogens are modulators not only of the adiposogenic process in the body, but also of the regional distribution of fat depots; they also affect the level of leptin circulating in the blood.

Many endocrine diseases - Itsenko-Cushing's disease and Cushing's syndrome, hypothyroidism, type 2 diabetes mellitus - are accompanied by weight gain; at the same time, of course, in laboratory tests, corresponding changes in the concentration of hormones are detected, which, in fact, determine the clinical and diagnostic picture of the disease.

However, the presence of only obesity as such in the absence of listed, well-defined endocrine diseases does not mean the absence of endocrine disorders in the body. For example, in obese individuals without hypothyroidism, blood levels of thyroid hormones are within the normal range. However, it is known that basal metabolic rate and thermogenesis, which are closely related to the action of thyroid hormones, are often reduced in obesity. This suggests a violation of the action of thyroid hormones on tissues, rather, not on everything (otherwise there would be a clinical picture of hypothyroidism), but, for example, on adipose tissue.

Although the basal levels of pituitary, adrenal and thyroid hormones in patients with so-called "exogenous-constitutional" or "alimentary-constitutional" obesity are also usually not changed, a detailed examination of a person often reveals more subtle hormonal abnormalities. So, the levels of somatotropic hormone - one of the most important fat-mobilizing factors - are within the normal range, but in most, if not all, obese individuals there is no increase in its concentration in response to specific stimulation (tests with insulin hypoglycemia, thyroliberin, levodopa, arginine and etc.). Therefore, it can be assumed that the level of lipolysis in adipose tissue under conditions of such a "latent" deficiency of growth hormone may decrease, and the accumulation of fat mass may increase. On the other hand, some authors consider impaired stimulated secretion of growth hormone secondary to obesity, since there is evidence that stimulated secretion of growth hormone is restored after weight loss.

Glucocorticoids (cortisol) suppress the anti-lipolytic effect of insulin on fat cells, especially those in the abdominal cavity, since the latter contain a large number of receptors for glucocorticoids. As a result, under the influence of cortisol, lipolysis and the flow of free fatty acids through the portal system to the liver increase; the described interaction may enhance hepatic insulin resistance.

In the process of developing abdominal obesity, there is an increase in the functional activity of the "corticoliberin - ACTH - adrenal glands" axis, with an increase in the production of cortisol. Increased secretion of corticoliberin can further lead to impaired secretion of growth hormone and gonadotropic hormones (LH and FSH), with the subsequent development of reproductive dysfunction. Over time, the functional activity of the hypothalamic-pituitary-adrenal axis is depleted, as a result of which, in individuals with already developed obesity, plasma glucocorticoid (cortisol) concentrations and their daily circadian rhythm remain within the normal range. However, the rate of decay of cortisol increases, and the rate of its production increases compensatory; sometimes, changes in cortisol secretion are detected in the dexamethasone test.

Perhaps the most pronounced and consistently occurring hormonal disorder in obese individuals is an increase in the concentration of insulin in the blood. Most often, it is detected in people with android (abdominal) and mixed types of obesity, much less often in the gynoid (femoral-gluteal) type of fat deposition. Hyperinsulinemia develops most likely secondary to insulin resistance. However, high levels of insulin itself stimulate appetite, hyperphagia and weight gain, thus forming a "vicious circle". As already mentioned, hyperinsulinemia and insulin resistance can play the role of a link between obesity, on the one hand, and arterial hypertension, dyslipidemia, and atherosclerosis, on the other hand. This is why many obesity experts believe that overweight individuals with hyperinsulinemia are a particularly high-risk group that primarily needs therapeutic and preventive measures.

The study of patients suffering from polycystic ovary syndrome and obesity attracted the attention of gynecologists and endocrinologists to the search for a possible relationship between insulin resistance, hyperinsulinemia and hyperandrogenism. Insulin resistance is found in polycystic ovary syndrome, even regardless of body weight. It is possible that insulin resistance and hyperisulinemia are a pathogenetic link common to polycystic ovary syndrome and obesity. Fluctuations in insulin levels under the influence of various medications are relatively correlated with the concentration of testosterone in the blood. The pituitary gland contains receptors for insulin. Hyperinsulimism and hyperandrogenism can disrupt the secretion of gonadotropins, increasing the level of luteinizing hormone. On the other hand, the use of antiandrogens does not always improve insulin sensitivity. It is logical to assume that weight loss or the administration of drugs that reduce insulin resistance (eg, metformin) and, secondarily, hyperinsulinemia, can eliminate hyperandrogenism and associated menstrual irregularities.

So, in the vast majority of obese people, at least with an in-depth examination, numerous disorders of hormonal secretion are detected, which do not fit into a clearly defined endocrine nosology, but, nevertheless, allow us to consider obesity - even "simple", or exogenous constitutional - as an endocrine disease. True, at the current level of knowledge, it is very difficult to clearly identify possible endocrine abnormalities in a particular patient, and it is almost impossible to influence them therapeutically in order to reduce body weight. Earlier in practice, attempts were made to treat obesity with thyroid hormones aimed at increasing basal metabolism and stimulating thermogenesis. They should be recognized as unreasonable and harmful, since weight loss could be achieved only when using very large doses of thyroid hormones, that is, in fact, by iatrogenic thyrotoxicosis, with all the ensuing adverse consequences, primarily for the cardiovascular system and bone fabrics.

5. Nutritional obesity - mechanisms of development

Many overweight people know that they are eating to relieve feelings of fear or grief. In the first year of a person's life, the relationship between mother and child is largely determined by food intake. Later, when the child already begins to eat independently, the mother or the person who has taken over the functions of the mother also prepares food and serves it on the table. Eating thus creates a largely unconscious fantasy of union with the mother. In this case, the mother may later be symbolically replaced by grocery stores, hotels or a home refrigerator. To be full means to be safe and not abandoned by the mother.

Alimentary obesity is a metabolic disease characterized by an increase in the volume of adipose tissue, a progressive course and a high tendency to relapse.

Speaking about alimentary (food) obesity, it must be remembered that this is a disease. This is important because society as a whole, and even medical professionals, tend to have a rather frivolous attitude towards being overweight. Meanwhile, the World Health Organization has recognized obesity as a new non-communicable epidemic, and the success of medicine in the fight against this epidemic seems to be more than modest.

Previously, it was believed that the basis of alimentary obesity is the excess of the energy value of food consumed over energy expenditure by the body. It is now firmly established that it is not only the amount of food consumed that matters, but also the imbalance of key nutrients, in particular, an increase in the proportion of fat in the diet.

Among all nutrients, fats have the highest energy value and are the most difficult to digest. In addition, the fate of alimentary fat in the human body is not the same at different times of the day.

So it is known that the main role in the assimilation of fat absorbed into the blood by body tissues is played by the hormone insulin. The intensity of secretion of this hormone during the day is not the same. Its maximum is at night, and its minimum is during the day. At the same time, the extraction of fat from adipose tissue is regulated by the sympathetic nervous system and mainly by adrenaline. The activity of the sympathetic nervous system is maximal during the daytime and minimal at night. Thus, the food eaten during the day, to a very small extent, turns into fat and is deposited in adipose tissue. The main deposition of fat in the depot occurs at night. Therefore, all nutritionists are advised to limit the evening meal to 18 hours.

Speaking about the obesity clinic, one should start with changes in a person's eating behavior. Human food-procuring behavior is determined by the feeling of hunger. In this case, it is necessary to distinguish between the concepts of "hunger" and "appetite". The feeling of hunger is evidence of the body's need for nutrients and occurs when blood glucose levels decrease. And appetite is the desire to eat something, which is most determined by a person’s food and taste preferences, therefore, excess appetite is a manifestation of not a physical, but a person’s psychological dependence on food. Obesity is characterized by dissipation (i.e., splitting) of hunger and appetite. This is what dictates nightly raids on the refrigerator, unconscious gluttony during stress, dependence on sweet and fatty foods. Refusal of these "small joys" of life is perceived by patients as a mental trauma, hence frequent failures in dieting, low effectiveness of therapy and a high relapse rate. Therefore, in such patients, psychological rehabilitation is a necessary component of therapy, the purpose of which is to reduce the psychological dependence on food.

The process of eating is determined not only by internal reasons, but also by various kinds of social pressure. Children are often forced to leave an empty plate after eating. Later it turns into a habit. Some people have a guilty conscience if they throw away food they haven't eaten, especially in restaurants and cafes where leftover food cannot be known to be reused for human consumption. At the same time, some people recall the starving people in other countries, which were often already told in families when the child did not want to eat. Of course, one person in a starving country will not become more full if someone in Germany indulges in gluttony. It is also important that many parents express their love through the offering of food or sweets. With the help of sweets, they seek to comfort children when they are in a bad mood.

In addition to the mental component, with obesity, significant changes are observed in the endocrine status of the body. Not only the level of secretion of insulin, growth hormone, adrenaline and norepinephrine changes, but also the sensitivity of body tissues to these hormones. Characteristically, sensitivity to insulin decreases earlier in muscle cells than in fat cells, and to adrenaline - on the contrary. In this case, the so-called "metabolic syndrome" develops, which is manifested by an increased risk of developing various diseases. These diseases include: type II diabetes mellitus, hypertension, atherosclerosis and its organ manifestations (in the vessels of the brain - dyscirculatory encephalopathy, stroke, in the coronary arteries of the heart - ischemic heart disease and its formidable complication - myocardial infarction, in the vessels of the extremities - obliterating atherosclerosis, gangrene of the extremities), increased risk of malignant neoplasms - breast, colon, prostate, endometrium. Since adipose tissue plays an important role in the breakdown of female sex hormones - estrogens, its excessive development leads to a lack of these hormones in a woman's body, which leads to premature menopause, menstrual irregularities, development of facial hair, complications during pregnancy and childbirth. . The musculoskeletal system suffers with the development of osteochondrosis, osteoarthritis, curvature of the spine, and joint deformities.

In the development of obesity, in all likelihood, constitutional and social factors that contribute to overeating play a large role. The existing psychological disorders in most cases do not create the impression of being particularly important, but their presence makes it necessary to consider issues related to their impact on the course of obesity as a disease.

For example, obese people often have low self-esteem, many of them feel insecure in society, there may be sleep disturbances in the form of hypersomnia or severe insomnia, persistent asthenization, manifested in reduced performance, low mood, irritability, sensitivity, impaired adaptive abilities to various changes in living conditions.

Psychopathologically, obese patients have depressive and anxiety-phobic disorders, which, in their opinion, are caused by a violation of socio-psychological adaptation. In all forms of obesity, to varying degrees, there are signs of damage to the nervous system and mental sphere. Undoubtedly, these changes in obesity are not accidental and differ quantitatively and qualitatively from those in diseases of the internal organs.

An analysis of the few data available in the literature on changes in the mental sphere in obesity shows that they can be divided into several groups.

First of all, these are psychological constitutional and personal characteristics that are related to psychogenic factors. Personally-structurally, they are determined by the desire to consume a large amount of food, due to which the development of the disease with the presence of biochemical, endocrine, metabolic disorders can be formed. The latter, in turn, can contribute to increased attraction as a psychogenic factor. Thus, a vicious circle is formed, which cannot be broken by dietary and drug treatment alone. There comes an improvement, clinically short-term, since one of the reasons is not eliminated - attraction and the dependence associated with it.

The second group of violations is secondary. They can be called personality-reactive changes, since they arise as a reaction of patients to their own somatic state, which changes their nature of social functioning. There are several types of these changes. One of the common reactions is to ignore the problem. This can manifest itself in the form of the formation of personality-typological features of hyperactive fat people, the creation of their own subculture, the formation of a style of behavior (the creation of their own style of clothing, works of art, clubs, etc.). These changes can be characterized as psychological agnosia or hypercompensation reactions.

Another type of secondary personality-reactive changes is the formation of depressive-neurotic disorders with painful experiences of a physical defect, reaching a neurotic depression at its peak.

Back in 1921, psychiatrist E. Kretschmer wrote that people with a picnic physique (abdominal obesity in the modern sense) often suffer from depression, stroke, atherosclerosis, and gout. In 1932 in persons with this symptom complex, a violation of carbohydrate metabolism, a decrease in insulin sensitivity, and autonomic dysfunction were detected. These works were the first to suggest a link between depression and a syndrome that was later called metabolic syndrome (MS). Recently, this problem has been actively studied, and although a few studies have not established an association between obesity and mental disorders, most of the accumulated data indicate a clear predominance of psychopathology in certain groups of obese people. The highest frequency of mental disorders (PD) was found in some categories of obese people - women, patients with morbid obesity, and also (which is especially important) in those who actively seek medical attention for weight loss (BW). In the Dresden Health Study, obese women had the highest incidence of AR; Anxiety disorders ranked first, followed by affective disorders (depression) and PR of childhood.

In morbid obesity, the frequency of subclinical and clinically significant anxiety and depression is significantly higher than in the population: more than half of people with a body mass index (BMI) > 40 have at least one PD. Most studies are devoted to studying the relationship between obesity and one of the most common PD - depression. Its prevalence during life in the population is about 17%, and in obese individuals - from 29 to 56%. General and abdominal obesity are not equally associated with psychopathological symptoms. In men, direct and indirect symptoms of depression and anxiety - depression scores - sleep disturbance, dyspepsia (the equivalent of irritable bowel syndrome, in the genesis of which anxiety and depression play a leading role), the use of anxiolytics, antidepressants, sleep disturbances - significantly correlate with the presence of abdominal obesity, those. with waist circumference (WC), but not with BMI. In women, anxiolytics and sleep disturbances are associated with BMI, while antidepressants and dyspepsia are associated with OT.

Thus, PD often precedes the development of obesity, especially in adolescents and young women with severe depression, but in a number of patients, on the contrary, depression develops after many years of obesity. This indicates the possibility of different pathogenetic variants of the association of obesity with PR.

Classical depression is accompanied by insomnia, loss of appetite and BW, while atypical, erased and somatized depressions often occur with drowsiness, increased appetite and BW increase. Both obesity and depression are often accompanied by eating disorders (EDS) and bulimia nervosa. Depressive disorder is present in anamnesis in 54% of obese patients with SPE and only in 14% of obese patients without SPE. Both in obesity, abdominal obesity and MS, and in depression, there is a high incidence of the same somatic diseases - arterial hypertension, coronary artery disease, stroke and type 2 diabetes. According to epidemiological data, obesity and depression (separately) are independent risk factors for the development of these diseases and increase the mortality associated with them.

Most obese people do not suffer from specific personality disorders (psychopathies), but they do have some personality traits. The most important of them is alexithymia, i.e. a reduced ability to recognize and name one's own feelings, combined with a limited ability to imagine. Alexithymia is present in about 8% of people with normal body weight and more than 25% of obese people, but usually only in those who have other psychopathological symptoms, such as anxiety or eating disorders. Individuals with alexithymia have a hypertrophied reaction to stress: against the general background of "inexpressiveness" of feelings, episodes of anger suddenly appear, often "unreasonable". Obese people who go to the doctor to reduce body weight, as well as women and people with morbid obesity, also have impulsiveness, unpredictability of behavior, passivity, dependence, irritability, vulnerability, infantilism, emotional instability, eccentricity, hysteria, anxiety-phobic and psychasthenic features. Impulsivity is reflected in the alternation of overeating and starvation, attempts to reduce BW and rejection of them. Failures with a decrease in body weight or in other areas of life exacerbate low self-esteem inherent in obese people, a sense of their own inadequacy, low self-efficacy (confidence in one’s ability to change something), closing the “vicious circle” with increased depression and anxiety. Characteristic features of thinking and perception, common to both obesity and depressive-anxiety disorders, are rigidity, a tendency to "get stuck" in emotions, "black-and-white" thinking (on the principle of "all or nothing"), catastrophizing (expecting the worst of all variants of events), a tendency to unreasonable generalizations ("I never succeed"), poor tolerance for uncertainty and expectation.

Thus, obesity is a psychosomatic disease, in the pathogenesis and clinical picture of which biological and psychological factors and symptoms are combined and interact. There are epidemiological and clinical associations between depressive and anxiety disorders, on the one hand, and obesity, MS, and associated somatic diseases, on the other. Although the majority of obese individuals in the population do not suffer from AE, some categories of patients have a clearly high prevalence of AE, which is accompanied by the development of obesity, including abdominal, and MS. In many cases, depression and anxiety precede the development of obesity, and the severity of mental symptoms is correlated with anthropometric and biochemical disorders characteristic of obesity. Depression, anxiety and obesity have a mutually negative effect on each other. The connection between obesity and PR is due to many factors, first of all, the commonality of some links in the central regulation of food intake and mood, i.e. serotonin - and noradrenergic neurotransmitter systems of the CNS, as well as the similarity of the functional state of the neuroendocrine system and psychological characteristics.

All of the above necessitates a holistic psychosomatic approach to the management of patients with obesity, which combines traditional medical programs for the correction of MT with psychotherapy aimed at eliminating the psychological problems that caused the development of obesity or that arose against its background. In this regard, the role of sibutramine as a drug of central action for the treatment of obesity, which through the serotonin and norepinephrine systems simultaneously affects both food intake and the psycho-emotional state of obese patients, is increasing. At the same time, the approach to treatment should also become more differentiated, since it is obvious that people with obesity and PR should be managed differently than those without PR. In the presence of clinically obvious depression or anxiety, it is advisable to start with the treatment of the relevant disorders and only then proceed to the actual BW correction program, otherwise the probability of a positive result is low. With less pronounced or erased symptoms of depression, the advantage in the treatment of a patient with obesity can be given to sibutramine, if possible in combination with psychotherapy or its elements.

6. Modern methods of treating obesity

Leading experts in the field of weight loss recommend a comprehensive approach to the treatment of obesity.

Current anti-obesity programs include:

examination of the state of human health; for the possible identification of the cause of overweight;

development of an individual program for gradual but stable weight loss;

treatment of concomitant diseases;

prevention of weight gain and maintaining it at the achieved level.

Before starting treatment, it is necessary to determine the goals of obesity therapy:

1. Weight loss (at a rate of no more than 7% per month); many authors suggest measuring the rate of weight loss in kilograms, but I think this is not correct, since weight loss is 0.5-1 kg. per week is not the same for a person with an initial BMI of 63 (160 kg.) or a BMI of 29 (62 kg.).

2. Maintaining the body weight reached at the new level and preventing re-gain of weight after losing weight;

3. Reducing the severity of risk factors / comorbidities.

Obesity is a chronic disease that should be treated for life.

If you have a body mass index (BMI) > 30 kg/m2 or a BMI > 27 kg/m2 but in combination with:

▪ abdominal obesity (ratio of waist circumference to hip circumference [RT/RT] in men >1.0; in women > 0.85);

▪ hereditary predisposition to type 2 diabetes, arterial hypertension;

▪ risk factors (increased levels of cholesterol, triglycerides, etc.);

▪ concomitant diseases (type 2 diabetes mellitus, arterial hypertension);

then treatment should be started immediately!

Before you start treating obesity, the first thing you need to do is change your lifestyle. No advertised drugs will give the desired effect without a gradual increase in physical activity and training in proper nutrition.

Obesity treatment methods.

Modern methods of treating obesity are divided into three main groups:

▪ Non-drug treatments for obesity

▪ Medical treatments for obesity

▪ Surgical treatments for obesity

Non-drug treatments for obesity include:

▪ Rational hypocaloric nutrition;

▪ Increasing physical activity.

psychotherapy.

Medical methods of treatment:

Before taking any drug, you need to consult with your doctor! After all, the vast majority of drugs that are so advertised and promising super-fast weight loss either have not passed clinical trials or are simply harmful to health (a large number of side effects, faster and more significant weight gain after the end of use, the appearance of drug dependence, etc.).

Modern requirements for an ideal drug for the treatment of obesity:

▪ must have a known mechanism of action;

▪ must significantly reduce body weight;

▪should have a positive effect on diseases associated with obesity (diabetes mellitus, arterial hypertension, etc.);

▪ must be well tolerated;

▪ should not cause dependence (addiction);

▪ must be effective and safe for long-term use;

Groups of drugs for the treatment of obesity:

1. The first group of drugs - anorectics, appetite suppressants (not used for long-term treatment of obesity!):

Side effects:

increased nervous excitability, insomnia, euphoria, sweating

diarrhea (diarrhea), nausea;

increased blood pressure, heart rate

the risk of developing drug dependence.

Characteristics of some drugs:

2. The second group - drugs that reduce the absorption of nutrients into the body:

act locally, in the lumen of the gastrointestinal tract

inhibit the enzyme lipase, due to which food fats are broken down and absorbed into the blood;

reduce the absorption of fats, which creates an energy deficit and contributes to weight loss;

prevent the absorption of about 30% of the ingested fats (triglycerides) of food;

help control the amount of fat in food;

do not affect the central, cardiovascular systems;

do not form addictions and addictions;

safe for long-term use.

Surgery.

Liposuction is a surgical (cosmetic) method for the treatment of obesity, based on the removal of excess fatty tissue from under the skin.

7. Psychology and psychotherapy in the treatment of alimentary obesity

The ability of people to form dependence is the main feature that characterizes their social essence. Addiction provides support, orientation, and empathy; without this ability, ties are weakened, promiscuity is possible, and independence is hardly feasible. The complete rejection of dependence in all cases indicates psychiatric disorders. At the same time, a more or less acutely ongoing process leading to the rejection of communications and free decisions is relevant.

Excess food intake is closely associated with an irresistible craving, a morbid passion, as in alcoholism. An alcoholic also "heals" an unpleasant state of mind and avoids building social relationships with alcohol, just like an overweight person does it with food. Similar to alcoholism, self-help groups for overweight people have worked well because they combine group dynamics with the patient's intelligent self. As a result, it then becomes easier to eat less. Treatment of excessive food intake (hyperphagia) is further complicated by the fact that lovers of a lot of food cannot completely refuse food, in contrast to alcoholism, in which a complete refusal of alcohol is quite possible. Controlled eating corresponds to controlled drinking in alcoholism, which is notoriously so difficult to achieve that most therapeutic schools reject controlled drinking as a goal of treatment. On the other hand, the social consequences of being overweight are not as significant as the social consequences of excessive alcohol consumption. Serious social pressure in this regard is still experienced primarily by women, which, in turn, may force them to overrestrict their diet or resort to artificial vomiting after eating. Like excessive drinking in alcoholism, excessive eating in obesity, which is self-destructive to the body, can sometimes be self-punishing. As with alcoholism, shame often plays a large role in obesity. Obese people eat in secret, just as alcoholics secretly drink, not only out of fear that they might be prevented from eating, but also because they are ashamed to overeat. They are also ashamed of their fullness, which, however, cannot be hidden. Therefore, they often prefer solitude.

The main problem in the treatment of obesity is the failure of purely pharmacological approaches traditional for modern medicine. Despite a large number of studies on the pharmacotherapy of obesity, all currently available drugs are only auxiliary, since they give only a slight, short-term effect and have pronounced adverse side effects. This applies to both centrally acting anorectics and lipase blockers of the gastrointestinal tract. The same applies to surgical methods of treatment.

Most of the causes of a psychological nature stretches, as a rule, from childhood. Parents force their children to eat everything, while citing a large number of "folk wisdom and proverbs" as an argument.

"Proverbs and Folk Wisdom"

Better a full stomach than a full mouth of worries, an insatiable womb (grabbing hands), swallowing resentment; take care of; food and drink connect the body with the soul (cf .: the stomach is stronger - it is easier on the heart); love passes through the stomach (cf .: the way to a man's heart leads through the stomach) ....

In this way, habits are formed, which in NLP are called programs. That is, each person is programmed from childhood to a certain set of behavioral stereotypes, these habits - programs, are formed as follows, if they praise their performance, then the habit will be fixed in character. Therefore, when a child is praised by the mother that he finished the meal (if you love your mother, finish it!). A stereotype is formed, finished food - there is love for mom. He is praised for having "respected the combine operator" who grew this bread, or the baker who baked it. A stereotype is formed - to eat up to the end, a manifestation of respect for society. Habits are fixed and go to an unconscious level. A person in the future, knowing a lot of diets, will sit down and eat everything.

Aspects of self-help: the development of obesity in terms of positive psychotherapy.

With rapid weight loss, the fat layer never disappears, but we are only talking about the loss of water, which is achieved due to the effect of dehydration. Obesity in less than 5% of cases is a symptom of an organic disease (Cushing's disease, hyperinsulinism, pituitary adenoma, etc.). It is in obesity, which is gladly presented as a consequence of organic disorders ("glands do not work"; "be a good utilizer of food"), mental and psychosocial factors play a decisive role. In addition to prescribing a controlled diet or fasting course, ask what is causing the person to eat more than is necessary. In addition to the experience from early childhood that food is more than just a supply of nutrients (e.g., attention to the mother, "sleeping" needs, reducing the feeling of displeasure), there are also concepts that we adopt in the process of parenting ("You should eat well to become big and strong", "it is better to burst than to leave anything to a rich owner" - thrift!). These are those that reflect our attitude to food, our eating behavior. The principle "Eating and drinking fasten the soul to the body" gives special meaning to the process of eating. Communication, attention, security and reliability are obtained according to the principle "Love goes through the stomach." Within the framework of the five-step positive psychotherapy, with the help of a positive approach and meaningful analysis (awareness of food concepts), the foundations of the full meaning of therapy are laid. Obesity is understood as a positive attitude towards the Self, as an actualization of sensations, primarily taste, the aesthetics of dishes, as a generosity and breadth of nature in relation to nutrition, as a commitment to established traditions in nutrition ("Those who are fat are beautiful"). Practical guidelines for the self-help aspect at the end of this chapter.

Therapeutic aspect: a five-step process of positive psychotherapy for obesity

Stage 1: observation/distancing.

Description of the case: "Better belly from food than a hump from work!"

A 44-year-old technician, who, with a height of 1m 78 cm, weighed 125 kg, came to me for a consultation on the advice of his family doctor, who was participating in the Psychotherapy Week in Bad Nauheimer. As is usually the case in such cases, no metabolic disorder was found in him. On the one hand, he complained only of being overweight, he had been treated for diabetes for six months and there were already signs of hypertension. On the other hand, it seemed that he fatally accepted his excess fullness as his fate. He came to the psychotherapist only at the urgent request of his family doctor, who for a long time had the opportunity to observe how all diets and sanatorium treatment courses failed unsuccessfully. It seemed that the patient felt superfluous in the psychotherapy session, looked at the situation of the reception room with interest and carefully tried to ignore me. The beginning of treatment was very difficult. The patient did not say anything, except for general information: about his marital status, professional activities and remarks that he was already accustomed to slander about his figure and therefore "he has no more complexes." When we started talking about his concepts, we got this dialogue:

Therapist: "What did your parents especially value? Food, school success, family time together, or did everyone have their own freedoms and preferences?"

Johannes: “Of course, they paid attention to school, but eating together was especially important for them. My mother was an excellent cook. of my favorite foods"

Johanies interrupted his story as if it pained him to talk about his family's eating habits. Therapist: "What was the motto in your house?"

Johannes: "Everything was very simple with us: food and drink fasten the soul to the body. I remember well how if I did not want to eat, I had to hear:" EVERYTHING that is served on the table must be eaten. "If I somehow "I could not eat it all, then the half-eaten food was warmed up for me again in the evening. If I did not want to eat, then I was told: there is nothing else. Every piece of bread from which I took a bite must be eaten by me without a trace. (Johannes smiled absently.) And we were also a storm of innkeepers. How we ate! We further had a proverb on this occasion: "It is better to burst than to leave something to a rich owner." In this I succeed even today When we have a feast at work, there is nothing left. I eat everything. My colleagues scoff: “Better a belly from eating than a hump from work.” (Johannes smiles contentedly. Large drops of sweat have appeared on his reddened forehead.)

A positive interpretation - "You treat yourself and your feelings well, first of all, the taste, the aesthetics of the dishes. You are generous with food" - laid the foundation for changing his point of view. Thus, we could easily move on to discussing ingrained eating habits.

We describe this case also in Positive Family Therapy to clarify the meaning of the concepts.

Stage 2: Inventory

Concepts of respect for food were drawn from the patient's childhood. We come to an experience that was meaningful to Johannes. When he was nine years old, his father died. It was war time, soon the post-war time came. Food was scarce and Johannes' mother constantly complained: "What are we going to do now that our breadwinner is dead?"

The role of the father was focused in his function as a provider of livelihood, and this concept was deposited in the mind of Johanies. Thus, food has acquired a symbolic character. She became for Johannes a symbol of the trust and security that he associated with his father. The thought of the death of the breadwinner and the subconscious conclusion that he himself would have to die of starvation led Johannes to the need to make sure again and again that there was still enough food. That's why he ate as much as he could and with every bite he acquired a steady sense of security. In doing so, he acted in accordance with family traditions of respect for food. Even today, he told us, his grandmother made sure he ate enough. When he returned home in the morning after working the night shift, he could not go to bed without eating. This was monitored by his grandmother, who could even wake him up, discovering that he had not eaten properly.

However, this need was also related to a well-known concept: he needed large earnings to be sure that he would always have enough food. In this regard, Johannes recalled stories about prisoners of war who, even years later, after being released, could not sleep without a piece of bread under their pillow. They simply could not cope with their memory of the famine they experienced many years ago.

Stage 3: Situational support.

So far, the emphasis has been on the observation and inventory stage. Johannes thus gained access to his problems. As much as Johannes spoke vividly about his food and excesses, so little did he seem to care about contact with other people. He was strongly impressed by the remark that contacts are part of the nature of man, and that he has an inherent need to communicate to the same extent as there is a need. But this did not prompt him to talk on this topic. His one-sidedness reminded me of a story about shared duties. It is not about guilt, idealization, negative qualities and one-sidedness. The only thing this parable can say to the patient is that in order to judge something, you need to see it in its entirety!

I told this story to Johannes. He used her as an excuse to talk about how he would like to have a girlfriend, but due to his appearance, he has not yet had a serious or long-term relationship. And then his thrift again helped him turn need into virtue: "A wife would cost me a pretty penny!", but unlike how he said before, Johannes said this ironically, no longer taking what was said seriously. As a counter-concept, I told him about the importance of contacts in the East, about how wide family ties can be, how contacts help to strengthen a person's sense of security and self-respect. Moving in the direction of differentiation, Johannes was able to see that his frugality and overeating served a substitutionary function: At the beginning of his relationship with his late father, then social contacts with other people.

Degree 4: Verbalization

At this stage, Johannes was able at first hesitantly and cautiously, then with curiosity, and finally, vigorously and persistently, to try the proposal to change his point of view. In parallel with this, his thrift was worked out.

Step 5: Expansion of the value system.

Stage 5 had already been laid, and Johannes no longer needed help with this. After he consciously changed his behavior regarding his concept of diligence and thrift and received positive feedback about it from his environment. It became not difficult for him to invite other people. At the same time, he had a stable relationship with one woman. Actually psychotherapeutic treatment took place in 15 sessions. During the last 7 meetings, the patient began to follow a diet (proper nutrition) at home, which this time was successful. Six months after the treatment, Johannes visited me again, he was calm and unperturbed, but it was a different calmness, he was unrecognizable. He lost 24 kg, now went in for sports and planned a big trip, which he wanted to connect with his sports hobby. His blood pressure returned to normal, and his diabetes no longer needed treatment. Losing weight so unloaded his fat metabolism that insulin production from his pancreas increased again. All this became possible not only due to the manifestation of willpower, but due to a change in his life principles and the expansion of his concept.

In the development of obesity, in all likelihood, constitutional and social factors that contribute to overeating play a large role. The existing psychological disorders in most cases do not create the impression of being particularly important, but their presence makes it necessary to consider issues related to their impact on the course of obesity as a disease. (Learning and Teaching Therapy, Jay Haley; The Guilford Press? New York, 1996. Translated by Yu.I. Kuzina.)

One of the most famous American psychotherapists of our time, K. Madanes, considers obesity the result of an unsatisfied (or not completely satisfied) desire to be loved. Family members so compete for attention and care. The struggle for care and attention often leads to the fact that a person harms himself or seeks punishment. Often there is excessive exactingness and criticism, complaints of pain and emptiness. Interaction between family members ranges from excessive interference to complete indifference to the needs of the other. In this case, family therapy is quite effective.

I had the opportunity to attend family counseling for a family in which a woman was overweight. Counseling was carried out by a psychotherapist Golovina I.A. Then I led this family for 3 months, which allowed me to observe the changes taking place.

Wife Elena, 28 years old, higher education, overweight (125 kg.), Attacks of high blood pressure began, her legs began to hurt. At the time of filing a complaint about bouts of compulsive eating in the evenings.

Before marriage and the birth of children, she had no problems with weight. The family has two children aged 3 and 4. Elena sleeps with her youngest child, her husband sleeps alone.

Not only Elena is interested in weight loss, but even to a greater extent her husband E. Alexei.

A family consultation was held, which was also attended by E. Anna Sergeevna's mother, who was also worried about her daughter's overweight. In her words, she, taking care of her daughter, always scolded her for being overweight and for eating a lot. A.S. herself has no excess weight.

In the course of family counseling, a program of recommendations was drawn up, which the spouses undertook to implement.

Program:

1. No one else keeps track of how much and how often E eats.

2. Spouses need to sleep together

3. If in the evening E. does not have an attack of compulsive eating, her husband gives E. a half-hour massage.

4. If E. takes 1 kg in a week. weight, mother E. takes the children to her place for the weekend, and E. and her husband spend 1 day off together. (Spend at the discretion of E .: cinema, walk ...)

5. If E. loses 4 kg in a month. then, at the end of the month, they spend 2 days off together (preferably outside the city)

6. If E. does not have a single attack of compulsive eating in a month, then the husband in the form of a "Bonus" gives E. a significant gift for her.

This program was developed together with the whole family and all family members agreed to follow these points.

A month later, E. lost 6 kg. weight, but during the first two months the bouts of compulsive eating continued. The frequency of attacks decreased. By the end of the 3rd month, the attacks stopped and by this time E. had already lost 15 kg.

Conclusion.

Recently, more and more attention is paid to the problem of overweight. The significance of the problem of obesity is determined by the disability of young people and a decrease in overall life expectancy due to the frequent development of severe concomitant diseases.

In the process of studying the literature on this topic, I came to the conclusion that Obesity is a multifactorial heterogeneous disease. The development factors of which can be:

1. genetic;

2. secondary obesity (as a result of damage to the endocrine system);

2. demographic (age, gender, ethnicity);

3. socio-economic (education, profession, social status);

4. psychological (nutrition, physical activity, alcohol, stress).

One of the most interesting questions in science is that in a person there is more biologically predisposed or socially determined. Did not bypass this question and this topic.

Population studies conducted in a number of countries have shown that the number of people with excessive body weight is 25-30%. Of the total number of these cases, 95% is primary obesity. And only 5% suffer from secondary obesity, which is a consequence of damage to the endocrine system, the current organic process in the central nervous system (tumor, trauma, neuroinfection) or genetic predisposition. [EAT. Bunina, T.G. Voznesenskaya, I.S. Korosteleva 2001] Thus, we can conclude that it is psychological factors that are important in the development of obesity. Excessive food intake leading to obesity in this case is:

A means of relaxation, discharge of neuropsychic stress

· A means of delectation (delectatio - lat. - pleasure, enjoyment), sensual, sensory pleasure, acting as an end in itself.

· A means of communication, when eating behavior is associated with communication between people, a way out of loneliness.

A means of self-assertion. Eating behavior in this case is aimed at increasing the self-esteem of the individual.

a means of knowledge. The process of eating always includes a cognitive component. Taste, visual, olfactory analyzers evaluate the quality of food, its safety and usefulness for the body.

A means of maintaining a particular ritual or habit. At the same time, eating behavior is aimed at maintaining national, family traditions, rituals and habits.

· Means of compensation, substitution of unsatisfied needs of the individual.

· Means of reward. Food, due to its taste, can serve as a reward for some actions that are positively evaluated by the social environment. Especially often this form of eating behavior occurs in childhood.

· Means of protection. R. Konechny and M. Bouhal indicate that excessive food intake, and after that the resulting change in appearance can serve as a means of protection against unwanted marriage (marriage), an excuse for failure in sports and work.

The result of a lack of love and attention from loved ones.

· A means of avoiding social contacts.I. p. t.

Thus, it can be concluded that there are a huge number of psychological factors underlying obesity. In the literature studied by me, more attention is paid to the presence of these factors and the mechanism of their influence and ways to eliminate these mechanisms are practically not described.

Study.

Organization, materials, research methods.

1. A group of subjects with a BMI over 29 (10 women, age from 22 to 45, education from secondary special to higher education, working, who applied for psychotherapeutic help to reduce weight)

2. Control group of subjects with BMI less than 25 (10 women, age from 22 to 45, education from secondary special to higher, working, not suffering from overweight)

3. Psychodiagnostic methods OHP, MMPI modified by Berezin F. B.

4. Method for determining the Ketle body mass index (degree of obesity).

To diagnose obesity and determine its degree, the body mass index (BMI, body weight in kg / height in m2) is used, which is not only a diagnostic criterion for obesity, but also an indicator of the relative risk of developing diseases associated with it. However, according to the recommendations of the WHO International Obesity Group from 1997, BMI indicators are not for children with an incomplete growth period, people over 65 years of age, athletes, for people with very developed muscles and pregnant women. BMI from 19 to 25 is recognized as the norm. Anything less than 19 is considered dystrophy, as for BMI from 25 to 27, this is overweight. A BMI that is more than 27 is already recognized as obese, so depending on body weight, obesity is distinguished:

1st degree (increase in weight compared to the “ideal” by more than 29%) BMI 27-29.5.

2nd degree (overweight is 30-49%) BMI 29.5-35;

3rd degree (overweight is 50-99%) BMI 35-40;

4th degree (excess body weight is 100% or more) BMI over 40.

Previously, a conversation was held on the subject of concomitant somatic or mental illnesses. On the basis of anamnestic data and conclusions, women were selected with various types of eating disorders that led to the formation of alimentary-constitutional obesity and who wanted to reduce body weight. The study did not include patients with secondary obesity, which occurs as a syndrome that develops in the pathology of the endocrine glands, with diseases of the central nervous system, patients with mental illness.

To study the psychological state of patients, the Minnesota questionnaire test was chosen as the main one, usually abbreviated MMPI (Minnesota Multiphasic Personality Inventory) in the modification of Berezin F. B.: it can be used to judge the significance of personal characteristics, the current mental state in pathogenesis and the formation of a clinical picture diseases, to study the characteristics of the mental sphere and psychosomatic relationships. This test was taken as the basis of the so-called psychological profile of the examined persons, since the quantitative assessment of the severity of mental changes, the possibility of statistical processing, the absolute comparability of data obtained by different researchers, allows us to consider the use of this psychodiagnostic technique as a tool that significantly increases the reliability of studies that involve the study of large populations to assess the effectiveness of mental adaptation, changes in mental state in various conditions (L.N. Sobchik, 1990; F.B. Berezin, 1994).

Results.

As a result of our study, the following results were obtained. For obese women, an eating disorder by the type of hyperalimentation, as a rule, is combined with neurotic symptoms, an increase in the profile on scales 4, 2, 1 and, to a lesser extent, 5 and 7 is typical (Fig. 1). This group is characterized by a tendency to increase search activity in a stressful situation. In this group of patients, the anxiety displacement mechanism does not bear the imprint of a clear connection between psychosomatic disorders and psychogenic factors. They are characterized by a mixed type of response: the achievement motivation is combined with the motivation to avoid failure, the propensity to be active is combined with the propensity to block activities under stress. Increased self-esteem, the desire for dominance is combined with self-doubt, excessive self-criticism. On the one hand, there is an "external" compensation of some traits by others, on the other hand, there is an increase in internal tension, since both behavioral and neurotic ways of responding are blocked. The internal conflict is canalized, as a rule, according to the psychosomatic variant, or it is manifested by neurasthenic symptoms rich in somatic complaints.

MMPI PROFILE OF FOOD ADDICTION PATIENTS. (Fig.1.)

Obese people are prone to health complaints, they have increased attention to their own somatic processes. There is "listening" to your body; all difficulties and a sense of threat are transferred from interpersonal relationships to internal processes; low emotional control, irritability, exactingness, anxiety, rigidity; there is a high probability of responding to psychotraumatic situations with an exacerbation of diseases of internal organs. In turn, complaints about health, a demonstration of one's physical ill-being allows one to interpret life's difficulties, as well as the inability to meet the expectations of others, inconsistency with one's own level of claims from a socially acceptable point of view. These reactions can be carried out, firstly, due to the affective presentation of existing disorders (the presence of severe obesity), which makes it possible to rationally explain the difficulty, and, secondly, due to the occurrence of non-psychotic pathopsychological symptoms (complaints of fatigue, irritability, inability to concentrate) . Complaints about the state of health can be used as a means of satisfying selfish tendencies.

Depending on the degree of obesity, there is some dynamics of MMPI scales. First of all, there is an increase in the rise on a scale of 1, which is most pronounced in patients with 3 tbsp. and 4 st. obesity, which indicates a greater degree of their concern about the somatic state, an increase in hypochondriacal tendencies and somatic complaints (which may well be associated with an objective deterioration in the somatic state due to an increase in body weight). There is also a slight rise on scale 2, indicating an increase in anxiety (it makes no sense to talk about obvious depressive tendencies in this case, except for stage 4, when, simultaneously with the rise on scale 2, there is a decrease in the profile on scale 9, indicating the appearance of depressive symptoms, manifested by anhedonic tendencies (a subjective feeling of lack of pleasure from previously interesting activities, an increase in passivity.) A decrease in social spontaneity, as a reaction to overweight, is also expressed in a decrease in the profile on a scale of 4 (more clearly manifested in the differences between 1 and 4 tbsp.) Also, in the direction from grade 1 to grade 4, there is an increase in scale 3, more pronounced in the transition from grade 1 to grade 2 and from grade 3 to grade 4, which indicates the activation of additional repression mechanisms, when the repressed anxiety does not manifest itself on behavioral level, but canalized according to the psychosomatic variant with the formation of “conditional pleasantness”. If we rise on scale 1, we can assume that in this way there is a kind of “adaptation” to excess weight, as well as its use in order to put pressure on others, or to “justify” one’s inability to meet “socially approved” standards, not only in bodily sphere, but also in the sphere of behavior. The initial rise in the profile on a scale of 8 is associated, presumably, not with personal characteristics characteristic of a schizoid personality, but with some autism, as a reaction to being overweight. As adaptation progresses (transition to grade 2), there is a decrease in the profile on this scale.

The inability to independently resolve crisis situations often leads mentally healthy individuals to partial mental maladjustment, which manifests itself in subclinical forms with polymorphic mild symptoms, which in turn, under the influence of social stress factors, can lead to neurotic or psychosomatic disorders with clinically defined symptoms with a high degree of probability. anxiety, depression, asthenia, etc. (Aleksandrovsky Yu.A., 1992). In general, I noted that people with food addiction are dominated by mechanisms such as denial, regression, compensation. Substitution, reactive formation, intellectualization, projection and repression are less pronounced. The combination of leading defense mechanisms and the degree of their intensity differ somewhat in different groups of patients.

Also, to identify psychological characteristics, I used the Questionnaire of Neurotic Disorders. The data using this method showed that people suffering from alimentary obesity show high scores on such scales as hypochondria, neurotic "overcontrol" of behavior (Fig. 2), while people without excess weight do not have hypochondria, they show high scores on the scale affective instability. (fig.3)

Average indicators of the results of the OHP of the group of subjects with alimentary obesity. personality scales. (fig.2)

Average indicators of the results of the OHP of the group of subjects without alimentary obesity. personality scales. (fig.3)

As for the special scales, OHP, the following data were obtained, in people with alimentary obesity, high indicators were found on the scale of drug abuse and paranoia (Fig. 4.), In people who are not obese and have a BMI of less than 25, high indicators on a scale of paranoid mood, as well as smoking abuse was detected in half.

Average indicators of the results of the OHP of the group of subjects with alimentary obesity. Special scales (Fig. 4)

Average indicators of the results of the OHP of the group of subjects without alimentary obesity. Special scales (Fig. 5)

In the process of experimental psychological research, we compiled a generalized psychological portrait of a person with food addiction. Analysis of the test results revealed the characteristic personality traits of a patient with impaired eating behavior, which led to the development of obesity of varying severity: isolation, distrust, restraint, increased anxiety, the predominance of negative emotions over positive ones, sensitivity, the desire for dominance, combined with self-doubt and excessive self-criticism , a tendency to easy frustrations, a high level of claims with a set to achieve high goals, hypersocial attitudes, a tendency to “get stuck” on emotionally significant experiences (“affective rigidity”). For such patients, on the one hand, there was an "external" compensation of some traits by others, on the other hand, there was an increase in internal tension, since the behavioral and neurotic ways of responding were blocked, and the internal conflict was often canalized along the psychosomatic variant, while all difficulties were tolerated. from interpersonal relationships to internal processes.

As the degree of obesity increased, there was an increase in hypochondriacal tendencies, which was most pronounced in patients with 3 and 4 degrees of obesity, indicating their concern about their somatic state. Patients with grade 4 obesity were characterized by obvious depressive symptoms, manifested by anhedonic tendencies (a subjective feeling of lack of pleasure from previously interesting activities, an increase in passivity). With an increase in body weight, a decrease in social spontaneity and an increase in emotional lability were observed, more pronounced when moving from one degree to another (from stage 1 to stage 2 and from stage 3 to stage 4), which indicated the inclusion of additional repression mechanisms when the repressed anxiety manifested itself not at the behavioral level, but was channeled along the psychosomatic variant with the formation of “conditional pleasantness”. Analysis of the generalized psychological profile of the MMPI test made it possible to identify signs of mental maladjustment associated with the insufficient effectiveness of existing defense mechanisms.

Thus, generalizing the psychological characteristics of a person with food addiction, we can talk about a person who, in a situation of increased emotional stress, uses hyperalimentation as a compensatory source of positive emotions. A change in eating behavior is one of the types of pathological adaptation, and food addiction in general is a mechanism for escaping reality, manifested by a combination of eating disorders of the type of hyperalimentation with mental disorders of a neurotic and personal level, leading to the development of overweight or obesity of varying severity. An experimental psychological study reveals the “parallelism and coherence” of mental and somatic manifestations and reveals an increase in psychopathological disorders with an increase in the degree of obesity, and the degree of alimentary-constitutional obesity, in turn, reflects the degree of spiritual distress. Therefore, in the process of psychotherapy of food addiction, it is necessary to identify and correct those personality traits that contributed to the formation of hyperalimentation as a form of response to psycho-emotional stress, as well as the formation of more adequate mechanisms for mental adaptation and more constructive behavior in the microsocium, more frequent use of adaptive variants of coinciding behavior for through the use of personal and environmental resources.

Conclusion

Alimentary-constitutional obesity is a classic psychosomatic disease. The cause of its occurrence is a violation of eating behavior, equated to mental disorders of the borderline level (Stunkard A. J. et al., 1980, 1986, 1990). Changing eating behavior is one of the types of psychological adaptation, a socially acceptable type of addictive behavior that is condemned, but not dangerous to others, unlike other forms.

In this paper, the psychosocial characteristics of overweight people were considered. As a result of the study, I can conclude that the hypothesis that obese people are united by the presence of certain psychological characteristics has been confirmed.

The purpose of this work was to identify the characteristics of the psychological sphere of obese people.

The main research methods were the psychodiagnostic methods OHP and MMPI (Minnesota Multiphasic Personality Inventory) modified by Berezin F.B. Based on the results of working with the scientific literature and my research, we can conclude. The personal-psychological sphere of the subjects is characterized by reduced resistance to stressful situations. A mixed type of reaction is inherent in them: the achievement motivation was combined with the motivation to avoid failure, the propensity to be active was combined with the propensity to block activity under stress. An increased sense of superiority, the desire for dominance was accompanied by a state of self-doubt, excessive self-criticism. On the one hand, there was an "external" compensation of some traits by others, on the other hand, there was an increase in internal tension, since both behavioral and neurotic ways of responding were blocked. Speaking about the psychological mechanisms in the formation of alimentary-constitutional obesity, we can conclude that a person with obesity, in a situation of increased emotional stress, uses hyperalimentation as a compensatory source of positive emotions. A change in eating behavior is one of the types of pathological adaptation, and food addiction in general is a mechanism for escaping reality, manifested by a combination of eating disorders of the type of hyperalimentation with mental disorders of a neurotic and personal level, leading to the development of overweight or obesity of varying severity.

1. A comparative psychodiagnostics of people with alimentary-constitutional obesity and people with normal weight as a control group was carried out.

1.1 People with obesity are characterized by the following psychological features: alexithymia; painful resentment; suspicion; the tendency to react to the influence of emotion without comprehending the situation; inadequacy of emotional reaction to social contacts; internal tension; difficulty in a real assessment of the situation and the general picture of the world; depressive tendencies; increased irritability and anxiety; increased sensitivity, rigidity; violation of interpersonal relationships; tendency to isolation, closeness; the desire to lay blame on others for the violation of interpersonal relationships and life's difficulties; passivity; dependence on others; hypochondriacal state with constantly depressed mood.

These tendencies manifested themselves in 8 people (80% of the subjects suffering from excess weight.)

1.2 When comparing the results of psychodiagnostics of obese people and people with normal weight, it was found that people who are not overweight have high scores on 9.0 MMPI scales and, unlike overweight people, low scores on 1.2 scales, people with normal weight is more characterized by such personal characteristics as independence; sociability; tendency to group; demonstrative forms of behavior, emotional brightness are combined with the desire for self-realization; high activity; self-confidence; enthusiasm, artistic temperament; low level of anxiety; feeling of importance; hyperthymic background; initiative; high self-esteem is maintained, while only 20% of obese people have some of these characteristics.

2. A person with obesity, in a situation of increased emotional stress, uses hyperalimentation as a compensatory source of positive emotions. A change in eating behavior is one of the types of pathological adaptation, and food addiction in general is a mechanism for escaping reality, manifested by a combination of eating disorders of the type of hyperalimentation with mental disorders of a neurotic and personal level, leading to the development of overweight or obesity of varying severity.

3. An indication for psychotherapy in people with alimentary-constitutional obesity is neurotic symptoms: a tendency to respond to the influence of emotions without comprehending the situation, inadequate emotional response to social contacts, internal tension, a hypochondriacal state with a constantly depressed mood, depressive tendencies. Recommendations for the provision of psychological assistance: Psychological assistance should be aimed at: normalization of intrapersonal well-being and the ability to optimally and adequately respond to exogenous psycho-emotional stress; set yourself up to believe in success and develop self-confidence; consistency in actions aimed at achieving results; development of motivation for healthy eating; clear formulation and formation of a weight loss program; rapid or gradual change in eating habits (stereotypes); the formation of psychological protection in a situation of food temptation or emotional stress.

In the process of complex psychotherapeutic treatment, various types of psychotherapy are used: rational, suggestive (Ericksonian hypnosis), personality-oriented, gestalt therapy, emotional stress, self-regulation, neurolinguistic programming.

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Obesity is the excess formation and deposition of adipose tissue in the human body. Usually occurs due to excessive intake of high-calorie foods and low physical activity. Over time, excess food is stored as fat. In our body, fat can be formed not only from fatty foods, but also from protein (meat, fish, eggs) and carbohydrate (sweets, muffins) foods. Obesity is a disease characterized by excessive development of adipose tissue (overweight of more than 20% of the norm).

Obese patients complain of increased appetite, especially in the afternoon, hunger at night, drowsiness, mood instability, irritability, sweating, weakness, shortness of breath. With significant obesity, Pickwick's syndrome develops (hypoxia and drowsiness as a result of poor ventilation of the lungs).

Due to the increased load on the musculoskeletal system, osteoarthritis occurs. Changes in the cardiovascular system are manifested by arterial hypertension. Skin lesions can be manifested by trophic disorders, furunculosis, seborrhea, small pink striae on the hips, abdomen, shoulders, armpits, hyperpigmentation of the neck, elbows and friction points. Women develop various menstrual disorders, infertility; in men, a decrease in potency. There is a high risk of developing type 2 diabetes.

Varieties of obesity

Specialists distinguish alimentary-constitutional, cerebral and endocrine forms of obesity. Causes alimentary-constitutional obesity is a genetic predisposition, constitutional features, systematic overeating, eating disorders (rich night meals for example), a diet high in animal lipids and easily digestible carbohydrates, physical inactivity. Cerebral obesity occurs as a result of traumatic brain injury, intoxication, brain tumors, stress. Endocrine obesity is a manifestation of the pathology of peripheral endocrine glands.

With the alimentary-constitutional form, fatty tissue is distributed evenly throughout the body; with the hypothalamic-pituitary - fat deposits are located more in the face, shoulder girdle, mammary glands, abdomen and limbs; with hypoovarian - in the pelvis and hips.

There are 2 types of general obesity: male (abdominal) and female (gluteal). According to the severity of the development of adipose tissue, 4 degrees are diagnosed: 1 - characterized by an excess of the ideal mass by 20 - 30%; 2 - by 30 - 50%; 3 - by 50 - 90%; 4 - more than 90%.

Obesity occurs in 12% of the population (women are 2 to 3 times more likely than men). Age over 40 increases the risk of developing this condition.

degrees of obesity. Self-diagnosis of obesity

You can determine if you are overweight by calculating your body mass index. Calculating it is quite simple - take your weight in kilograms and divide by your height squared in meters. With normal body weight, the body mass index is 18.5 - 24.5. With obesity of the 1st degree, the body mass index is 30 - 35. With obesity of the 2nd degree, the body mass index is 35 - 40. With obesity of the 3rd degree, the body mass index is more than 40.

A simple approximate method for diagnosing obesity is to determine the thickness of the fat fold in the epigastric region (normally 1 - 1.5 centimeters, with obesity - more than 2 centimeters).

For example, with a height of 1 meter and 75 centimeters and a weight of 80 kilograms, the body mass index is 80 divided by 1.75 squared. This will be equal to 26.12. It turns out that there is either a slight excess weight or a person has an optimal physique, but obesity is still far away. True, this method of determining the ideal weight does not pay attention to the difference between the male and female figure, as well as the percentage of adipose and muscle tissue in the body. People who play sports and have a muscular build will have the same body mass index as people who already have a little body fat. However, body mass index remains the only recognized international criterion for assessing excess weight. For objectivity in determining the optimal proportions, it is necessary to pay attention to various data.

Obesity is a chronic problem, over time, "thanks" to it, such diseases develop: diabetes mellitus, hypertension, myocardial infarction, cholelithiasis, varicose veins, arthrosis of the joints.

Causes of obesity

Obesity develops as a result of an imbalance between the amount of energy entering the body and expended during the day. People who are prone to weight gain usually receive much more energy than they expend. Excess energy accumulates and is deposited in the form of subcutaneous and internal fat. There are a number of reasons that contribute to the development of obesity: a sedentary lifestyle, genetic factors (heredity), disruption of the endocrine glands, a tendency to stress, constant lack of sleep, often using various diets.

obesity treatment

It is necessary to treat obesity in a complex. Be sure to include a certain diet and increase physical activity. A balanced low-calorie diet is recommended. .Limit energy intake to 1200 - 1500 kilocalories per day. Easily digestible carbohydrates, fats of animal origin are limited in the diet (at least 50% of lipids should be of vegetable origin), table salt up to 5 grams per day, liquid up to 1 - 1.5 liters per day. The diet should include 90 - 120 grams of protein, 40 - 80 grams of fat, 100 - 120 grams of carbohydrates and a sufficient amount of vitamins and minerals. For the treatment of obesity, foods high in fiber are recommended. contributing to rapid saturation. Food fractional, 5 - 6 times a day. Fasting days are held 1 - 2 per week: protein days (cottage cheese - 5 grams of cottage cheese per day; meat - 250 - 350 grams of boiled meat or fish), carbohydrate (apple - 1.5 kilograms of apples and rice porridge from 75 grams of rice and 450 grams of milk; curd-kefir - 400 grams of cottage cheese and 700 milliliters of kefir). Complete fasting is possible only in a hospital setting or after preliminary self-training.

With increased appetite, anorexigenic drugs are prescribed: fepranone, teronnac, deopimone, fenfluramine. The course of treatment is about 1 - 1.5 months. Since this group of drugs has a stimulating effect, it is recommended to use them in the morning. To stimulate lipolysis, adiposin, metformin are prescribed. In the initial period of treatment, it is possible to use diuretics: hypothiazide, furosemide or herbal preparations (buds and birch leaves, horsetail and others) - for 1 to 2 weeks. 3 - 4 degree of obesity, the initial manifestations of Pickwick's syndrome are indications for surgical treatment.

To enhance metabolic processes in alimentary obesity, cold procedures are prescribed - wet rubdowns of the body, douches, cool showers, contrast baths.

With alimentary obesity without violations of the cardiovascular system, thermal procedures are indicated.

1. Light and heat baths (55 - 60 C), for 10 - 15 minutes, every other day.

2. General wet wraps lasting from 45 to 60 minutes, followed by a rain shower 36 - 37 C.

3. Thermal baths - hot fresh baths, baths with a temperature rising from 35 to 41 C and hot dry air baths.

4. Finnish sauna or Russian steam room.

To improve the function of the endocrine, nervous, cardiovascular and digestive systems, mineral waters are used in the form of baths, bathing in a mineral water pool, ingestion and intestinal lavage. Sulfide, carbonic, radon, chloride baths are used.

Treatment of obesity should be carried out for a long time, within 1 - 2 years. Body weight should decrease gradually. A rapid, significant decrease in it in the case of the return of the patient to the previous way of life gives the opposite effect.

Among the physical methods of rehabilitation, physiotherapy is of great importance in the treatment of obesity, morning hygienic exercises, dosed walking, sports exercises (running, rowing, swimming, cycling), outdoor and sports games are used. It is advisable to use occupational therapy and general massage.

An obesity treatment program must be developed individually for each person based on the state of health and the reasons that caused this problem. Someone needs to pay more attention to nutrition, and someone needs to activate their own physical activity.

You can learn more about the different ways to lose weight here Weight Correction

Additional articles with useful information

Having started to lose weight, a person faces many difficulties, and one of them, which is most often forgotten at first, is what is my ideal weight to strive for.

To combat excess weight, you need to use many tools, and one of them, without which it is almost impossible to do, is physical exercises that burn fat.

Primary, or exogenous-constitutional (alimentary) obesity. This type of obesity accounts for up to 97% of all forms of weight gain. In the anamnesis of these patients, there are very often indications of obesity in the next of kin, a stereotype of abundant nutrition that has been preserved since childhood, as well as an increase in body weight during periods of recovery from acute diseases; almost everyone has a decrease in physical activity.

Complaints in persons with I and II degree of obesity may not be, and the existing ones are more likely to be associated with cosmetic changes in appearance. Faster than others, there are complaints from athletes, artists, when excessive body weight leads to a deterioration in professional and sports performance. Some patients develop malaise, fatigue, shortness of breath during normal exertion, palpitations and pain in the heart, in the epigastrium and right hypochondrium, a feeling of fullness in the pit of the stomach after eating (especially greasy), dry mouth, and a tendency to constipation. Frequent complaints are headache, decreased sexual potency in men and menstrual disorders in women.

On examination, there is a uniform excess deposition of fat in the subcutaneous tissue, stretch marks on the skin, acne vulgaris, rarefaction of the hairline, trophic skin disorders, and pastosity on the lower extremities.

Due to the restriction of excursions of the diaphragm and an increase in intra-abdominal pressure due to the increased fat content in the abdominal cavity, the function of external respiration is impaired, and the diffusion permeability of lung membranes decreases. These changes subsequently lead to the formation of cardio-respiratory insufficiency and to an easier occurrence of various inflammatory diseases of the respiratory system. The course of pneumonia in these patients is more severe, and the likelihood of respiratory disorders in the postoperative period is higher. With severe obesity, Pickwickian syndrome can form.

Changes in the cardiovascular system are observed in 80% of obese patients. More often than other vascular changes, arterial hypertension is recorded, less often - electrolyte balance disorders, sometimes hyperaldosteronism. In comparison with people with normal body weight, patients with obesity are 3 times more likely to have manifestations of atherosclerosis of peripheral arteries, angina pectoris. The vast majority of obese individuals have dysmetabolic myocardial dystrophy.

Increased body weight also contributes to the disorder of the functions of the gastrointestinal tract. Patients often have gastritis with increased secretory activity, intestinal dyspepsia, flatulence, constipation. Radiologically determined stretching and prolapse of the stomach. There is no doubt that obesity is associated with an increase in cholelithiasis, fatty hepatosis and cholecystitis. Low-symptomatic disorders of pancreatic function are present in 95% of patients. The frequent combination of hyperinsulinism with impaired glucose tolerance is surprising. Type II diabetes mellitus in these patients can be both latent and overt, but its course is often milder.

Operations carried out as necessary in obese patients are more technically difficult, accompanied by complications. In overweight individuals, there are changes in the stagnant nature of the kidneys, nocturia, and a tendency to form urate stones. Gout is also more common. In obesity, the daily excretion of 17-hydroxycorticosteroids in the urine is often increased, and blood plasma cortisol also rarely increases. In women with obesity, the early cessation of menstruation and the onset of menopause are regular.

With severe obesity, the development of other disorders also accelerates: deforming osteoarthritis, especially of the hip joints, therefore, the “duck” gait also becomes characteristic; osteochondrosis of the spine with radiculitis of various localization; varicose veins; thromboembolic complications; ventral and diaphragmatic hernias. At the same time, in assessing the risk of visceral pathology, not only the degree of obesity is important, but also the nature of the bodily distribution of fat. A significant accumulation of abdominal fat entails a high risk of developing dyslipidemia, cardiovascular disease, type II diabetes mellitus and an increase in mortality as a result.

It is important to identify early degrees of exogenous obesity. With obesity of the IV degree, the issue of transferring the patient to disability and changing the nature of work is being resolved. But in comparison with other forms of obesity, alimentary obesity is a relatively benign and slowly progressive form, it rarely leads to fatal complications.

Diagnostics.

The most important studies in assessing the degree of obesity are anthropometric data, comparison of actual body weight with ideal; the issue of the nature of obesity is more difficult to resolve, which makes it easier to carry out differential diagnosis with secondary forms of obesity. If a morphological study is possible, then it becomes obvious that fat cells in alimentary obesity reach enormous sizes (up to 300 microns 3).

Treatment.

Anorectics of various pharmacological groups (desopimone, amfepromon, isolipan, mazindol (teranac)), inhibiting appetite. But these drugs have many side effects. Fewer adverse effects with diethylpropine ifenfluramine, a xenical lipase inhibitor (ormistat).

When obesity is combined with type II diabetes mellitus, Siofor 500/850 is recommended, which has a multicomponent effect. Thyroid hormones (triiodothyronine and L-thyroxine) increase thermogenesis. Apply and means of general metabolic action - vitamins C, B6, lipoic acid, statins.

Sources of information:

1. Harrison's Handbook of Internal Medicine
2. Fedoseev G.B., Ignatov Yu.D. Syndromic diagnosis and basic pharmacotherapy of diseases of internal organs.
3. Borodulin V.I., Topolyansky A.V. Practitioner's Handbook.
4. Roitberg G.E., Strutynsky A.V. Laboratory and instrumental diagnostics of diseases of internal organs.

If you have developed a second degree of obesity, you need to urgently prescribe a treatment that will begin weight loss. We will tell you what diet should be followed in order to remove extra pounds, plus we will explain how to cure a rather popular diagnosis - exogenous constitutional obesity of the 2nd degree.

Obesity is a disease that has negative consequences. It implies fatty deposits in organs, subcutaneous tissue and other tissues. The first sign of pathology is an increase in body weight and adipose tissue by at least 20%. Today, 4 stages of obesity are distinguished, while in the first two the situation can still be corrected and lose weight. According to statistics, today in Russia the number of people suffering from excess weight is increasing.

Second degree of obesity

If the disease was not detected at the initial stage and appropriate measures were not taken, then the second degree of obesity occurs. At this stage, the volume of body fat is from 30 to 50% of the total body weight.

Pathology is detected as a result of a comprehensive examination. At the same time, tests are given for the level of sugar, sex hormone and obesity hormone.

Diagnosis should be carried out only by a doctor who will tell you how many kg and how you can lose. Although, according to the characteristic symptoms, the presence of a problem can be determined independently.

The main signs of the 2nd degree of obesity are:

• a set of kilograms, while the deviation from the norm will be approximately 30-40%;
• shortness of breath appears even with minor exertion;
• growth of body fat in the waist area;
• sweating increases;
• heartbeat quickens;
• pathological weakness;
• limbs also swell, often this symptom manifests itself in the summer.

If stage 2 of the disease is diagnosed, then the person may not be bothered by anything. In some cases, there may be a feeling of nervousness, drowsiness, mood changes dramatically, appetite increases and stretch marks form on the hips and abdomen.

Treatment of obesity 2 degrees

Treatment of overweight of the 2nd degree is carried out in a complex manner. Moreover, the methods in each case are selected individually. Conventionally, the entire course is divided into 2 stages: weight loss and then weight stabilization. Often, overweight is prescribed and drug treatment.

Treatment of obesity of the second degree includes the following steps:

Exogenous-constitutional obesity of the 2nd degree

A fairly common cause of this problem is a hereditary factor. This form is called exogenous-constitutional. At the same time, a person has a predisposition to the accumulation of fats due to the intake of a large number of calories. Exogenous constitutional obesity of the 2nd degree is quite simple to treat, because it is not a disease caused by a violation of the hormonal cycle.

In this case, it is necessary first of all to reconsider nutrition. Avoid overeating, which is typical for patients with hereditary fullness. In addition, constant physical activity is required, walking should not be neglected, and if driving can be replaced by walking, then this should be done.

Regardless of the form and degree of obesity, it will not go away on its own, so proper treatment is required. Therefore, the effectiveness of therapy depends on the timeliness of contacting a specialist.

Diet for obesity of the second degree

By reducing the amount of calories consumed - this is what the diet should be aimed at for obesity of the second degree. Thus, the norm per day is 700 - 1800 kcal, it depends on weight and height.

In addition, it is necessary to regulate the use of the following substances, which are presented in the table.

At the initial stage of the treatment of obesity of the second degree, it is better to start without excessive restrictions (basic diet). At the same time, the dishes should be quite varied so that the desire to break loose is minimal.

Be sure to make the menu so that it includes all the necessary vitamins and amino acids. But, from the use it is important to exclude flour, sweet, fried, fatty, peppery and salty. Dishes should be prepared by baking, carcass and boiling.

Over time, when after a properly selected diet there will be results, you need to enter fasting days.

Vladimir Mirkin, nutritionist.

When preparing food, in order for the diet to be more effective, first courses should be as liquid as possible. As for the second courses, I recommend moving away from the principle of restaurants, you do not need to use a side dish with protein products, either this or that. Flour, sweets and potatoes are foods that provoke weight gain, so they should be completely excluded.

The principle of proper nutrition for obesity of the second degree is to:

• limit the amount of fats, carbohydrates and proteins consumed;
• create a feeling of satiety with low-calorie foods;
• form the correct diet (5-6 times);
• use of fasting days;
• normalize water-salt metabolism by reducing salt intake.

Despite the fact that obesity of the second degree is a neglected form, it is not difficult to treat it, the main thing is to be patient and motivate yourself. To do this, it is better to keep a diary, which notes not only the food that was consumed during the day, but also the results. And not enough weight marks, you need to indicate the volume of the waist, chest and other things.

Following all the prescriptions of a specialist (diet, exercise and giving up bad habits), the weight will go away at a moderate pace.

Some scientists believe that the cause of extra pounds is the slagging of the body, which it fights well with. Next, we posted instructions for use on Normolife, since the price on Normalife is really justified.

Perhaps you will be interested in children and adults.

Obesity is divided into several types - according to the reasons that cause it, and according to degrees - depending on the amount of adipose tissue. The location of fat deposits, the size of skin folds, changes in the skin, the number of stretch marks, body elasticity, etc. are taken into account. Alimentary obesity (or exogenous-constitutional) is the primary form of accumulation of adipose tissue that develops in children and adults who are prone to fullness.

Development mechanism

Exogenous-constitutional obesity occurs when the calorie content of the food consumed significantly exceeds the energy expended. Calories entering the body may simply not be absorbed due to a violation of the functions of the digestive tract, or they may simply significantly exceed the amount required. In the second case, we are talking about the usual overeating.

Excess nutrients are converted into fat and accumulate in the subcutaneous tissue and form a "pad" around all internal organs. Normally, all internal organs should be surrounded by a layer of fat, but its total mass in a healthy adult should not exceed 3 kg. With obesity, the weight of the layer, if put together, can be 10-15-20 or more kilograms.

With alimentary obesity, the weight increases gradually and the layer of fat is distributed evenly. Complaints about the state of health are rare, and constitutional changes do not concern. They do not make diagnoses regarding pathologies of the endocrine or cardiovascular system, do not note any organic changes - metabolic disorders.

The primary set of fullness develops with low physical activity, the secondary one is associated with impaired CNS function.

There is another theory of the causes of the development of pathology - products that are genetically modified or with excessive accumulation of foreign substances. Unfortunately, when raising animals and poultry, manufacturers use hormones and drugs, agricultural products are “stuffed” with fertilizers, and toxins and heavy metals accumulate in seafood.

Causes of alimentary obesity

If we divide the causes of obesity by etiology, we can distinguish internal and external factors.

1. Internal (endogenous) - the main cause of constitutional changes - unhealthy heredity. If one of the parents - or both - were overweight, then the likelihood that their child will be overweight is quite high. The rate of metabolic processes is also inherited; endogenous causes include changes in the hormonal background - pregnancy, menopause, lactation; sensitivity to the perception of satiety and hunger. The hypothalamus is responsible for the latter function.
2. External (exogenous) factors are reflex, that is, eating habits. For example, a habit has formed when watching TV to always chew something - nuts, crackers, sweets. Or - you often have to deal with how problems “seize”, food intake helps to cope with stressful situations.

Exogenous factors also include hypodynamia - a disease of our time. Physical inactivity is an inactive lifestyle that affects both adults and children.

Influence constitutional features and national traditions - the habit of plentiful feasts.

Regardless of the genesis of primary obesity, the examination must take into account its type. Primary forms are divided into the following categories:

• Android - fat accumulations are located in the abdomen and chest, closer to the armpits; occurs more often in men - this category includes abdominal obesity, in which fat is deposited in the abdomen and increases the cushioning layer around the internal organs located in the peritoneum and pelvis;
• Gynoid type - more common in women. The fat layer is located on the hips and on the abdomen, but not at the level of the waist, but below, in the projection of the uterus.
• Mixed type - fat is evenly distributed.

There are 4 degrees of completeness - depending on the volume of body fat relative to the total body weight:

1 degree - in relation to normal body weight, excess adipose tissue 10-29%;

2 degree - from 29 to 50%;

3 degree - from 50-98%.

Obesity of the 4th degree is extremely dangerous, weight - compared to normal - is doubled, and it is due to body fat.

In especially severe cases, the patient's weight may exceed normal - 3 or even 4 times.

How to diagnose pathology

The easiest way to make a diagnosis:

• measure the waist - for women, the limit value is 80 cm, for men - 94-95 cm;
• measure the waist and hips, and correlate them - divide the "hips" by the "waist"; if men get a value of 0.94 and below, and for women - 0.85 and below, then there are no problems with being overweight;
• determination of BMI - body mass index.

To determine BMI, many tables have been developed - they can be found in the medical literature or on Internet sites dedicated to weight loss.

Approximately, the BMI value is calculated using the simplest formula: weight divided by the square of height divided by 100.

« obesity calculators”are also presented on Internet sites that promise to get rid of “extra pounds” after acquiring miracle remedies. It is enough to drive in the required parameters - weight, height, wrist or hip volume, and you will receive an assessment of the condition and recommendations for losing weight absolutely free of charge and within a few minutes.

When making a diagnosis in a medical institution, more complex calculations are used, which take into account not only the ratio of the height and weight of the patient, but also constitutional features, age, history of diseases, even racial differences. The thickness of the skin fold on the abdomen, the distribution of fat, the presence or absence of stretch marks are taken into account ...

Treatment requires alimentary obesity, starting from the 2nd degree of pathology - it must be borne in mind that with exogenous etiology, medications lead to a slight improvement and do not fix the result for a long time. You should also not switch to popular diets, choosing the one you like.

Treatment Methods

To eliminate body fat, they develop a special diet - their own for each patient - taking into account concomitant diseases and food addictions.

Calories are calculated individually.

Common in such diets:

• restriction of simple carbohydrates and fats;
• exclusion of salt;
• limiting the amount of daily fluid intake - in ordinary diets, the drinking regimen needs to be expanded to the maximum;
• in the daily menu, fiber must be present, which enters the body in the form of vegetables and fruits, more often in raw form.

The exercise therapy complex is also selected on an individual basis. General recommendations - classes in the pool. During water training, there is a minimal risk of damage to the joints of the lower extremities. All other loads are determined depending on the patient's condition.

Patients are often advised to consult a psychotherapist or psychologist - the decision on individual or group sessions is made by the doctor. It is necessary to change eating and behavioral habits, to correctly form the motivation for losing weight - otherwise it is impossible to get rid of excess weight.

Complex therapeutic measures for the treatment of alimentary obesity - diet therapy, physical activity, lifestyle adjustment. They try not to prescribe medications. Successful treatment is possible only if the patient wants to lose weight.

In order to prevent a recurrence of the condition, recommendations for losing weight will have to be followed throughout life. (In the case of children, the problem of rapid weight gain may be solved after the final hormonal formation - after puberty).